Siska Van Bruwaene

The use of sling vs sphincter in post‐prostatectomy urinary incontinence

The artificial urinary sphincter (AUS) is considered the ‘gold standard’ in post‐prostatectomy urinary incontinence. However, in recent years, male slings have gained much popularity due to the ease of surgery, good functional results and low complications rates. This review systematically shows the evidence for the different sling systems, describes the working mechanism, and compares their efficacy against that of the AUS. Furthermore subgroups of patients are defined who are not suited to undergo sling surgery.

A standardized resident training program in endoscopic surgery in general and in laparoscopic totally extraperitoneal (TEP) inguinal hernia repair in particular.

The need for acquisition of specific laparoscopic skills has emphasized the role of a preclinical laboratory-training program. However, for laparoscopic inguinal hernia repair with a steep learning curve, especially for totally extraperitoneal repair, preclinical skill training remains a challenge. A standardized preclinical resident training program in endoscopic surgery is described. Also, a standardized clinical training program is proposed with systematic dissection in 10 different consecutive steps for totally extraperitoneal inguinal hernia repair. Continuous mentoring by an expert is an absolute prerequisite to the success of this training program. In this way, the learning period may be drastically reduced to approximately 30 procedures, in whom the resident progressively performs more and more of the different steps, and ultimately the complete procedure. Validation studies at different institutions are starting up to demonstrate the additional value of this training program.

Laparoscopy Training in Surgical Education: The Utility of Incorporating a Structured Preclinical Laparoscopy Course into the Traditional Apprenticeship Method

OBJECTIVE To investigate whether preclinical laparoscopy training offers a benefit over standard apprenticeship training and apprenticeship training in combination with simulation training. DESIGN This randomized controlled trial consisted of 3 groups of first-year surgical registrars receiving a different teaching method in laparoscopic surgery. SETTING The KU LEUVEN Faculty of Medicine is the largest medical faculty in Belgium. PARTICIPANTS Thirty final-year medical students starting a general surgical career in the next academic year. METHODS Thirty final-year medical students were randomized into 3 groups, which differed in the way they were exposed to laparoscopic simulation training but were comparable in regard to ambidexterity, sex, age, and laparoscopic psychomotoric skills. The control group received only clinical training during surgical residentship, whereas the interval group received clinical training in combination with simulation training. The registrars were allowed to do deliberate practice. The Centre for Surgical Technologies Preclinical Training Programme (CST PTP) group received a preclinical simulation course during the final year as medical students, but was not exposed to any extra simulation training during surgical residentship. At the beginning of surgical residentship and 6 months later, all subjects performed a standardized suturing task and a laparoscopic cholecystectomy in a POP Trainer. All procedures were recorded together with time and motion tracking parameters. All videos were scored by a blinded observer using global rating scales. RESULTS At baseline the 3 groups were comparable. At 6 months, for suturing, the CST PTP group was better than both the other groups with respect to time, checklist, and amount of movements. The interval group was better than the control group on only the time and checklist score. For the cholecystectomy evaluation, there was a statistical difference between the CST PTP study group and both other groups on all evaluation scales in favor of the CST PTP group. CONCLUSIONS Structured, preclinical proficiency-based training is better than clinical training combined with laboratory training or clinical training alone.

Designing the selenium and bladder cancer trial (SELEBLAT), a phase lll randomized chemoprevention study with selenium on recurrence of bladder cancer in Belgium

BackgroundIn Belgium, bladder cancer is the fifth most common cancer in males (5.2%) and the sixth most frequent cause of death from cancer in males (3.8%). Previous epidemiological studies have consistently reported that selenium concentrations were inversely associated with the risk of bladder cancer. This suggests that selenium may also be suitable for chemoprevention of recurrence.MethodThe SELEBLAT study opened in September 2009 and is still recruiting all patients with non-invasive transitional cell carcinoma of the bladder on TURB operation in 15 Belgian hospitals. Recruitment progress can be monitored live at http://www.seleblat.org Patients are randomly assigned to selenium yeast (200 μg/day) supplementation for 3 years or matching placebo, in addition to standard care. The objective is to determine the effect of selenium on the recurrence of bladder cancer. Randomization is stratified by treatment centre. A computerized algorithm randomly assigns the patients to a treatment arm. All study personnel and participants are blinded to treatment assignment for the duration of the study.DesignThe SELEnium and BLAdder cancer Trial (SELEBLAT) is a phase III randomized, placebo-controlled, academic, double-blind superior trial.DiscussionThis is the first report on a selenium randomized trial in bladder cancer patients.Trial registrationClinicalTrials.gov identifier: NCT00729287

An evidence-based laparoscopic simulation curriculum shortens the clinical learning curve and reduces surgical adverse events

Background Surgical simulation is becoming increasingly important in surgical education. However, the method of simulation to be incorporated into a surgical curriculum is unclear. We compared the effectiveness of a proficiency-based preclinical simulation training in laparoscopy with conventional surgical training and conventional surgical training interspersed with standard simulation sessions. Materials and methods In this prospective single-blinded trial, 30 final-year medical students were randomized into three groups, which differed in the way they were exposed to laparoscopic simulation training. The control group received only clinical training during residency, whereas the interval group received clinical training in combination with simulation training. The Center for Surgical Technologies Preclinical Training Program (CST PTP) group received a proficiency-based preclinical simulation course during the final year of medical school but was not exposed to any extra simulation training during surgical residency. After 6 months of surgical residency, the influence on the learning curve while performing five consecutive human laparoscopic cholecystectomies was evaluated with motion tracking, time, Global Operative Assessment of Laparoscopic Skills, and number of adverse events (perforation of gall bladder, bleeding, and damage to liver tissue). Results The odds of adverse events were 4.5 (95% confidence interval 1.3–15.3) and 3.9 (95% confidence interval 1.5–9.7) times lower for the CST PTP group compared with the control and interval groups. For raw time, corrected time, movements, path length, and Global Operative Assessment of Laparoscopic Skills, the CST PTP trainees nearly always started at a better level and were never outperformed by the other trainees. Conclusion Proficiency-based preclinical training has a positive impact on the learning curve of a laparoscopic cholecystectomy and diminishes adverse events.

Porcine cadaver organ or virtual-reality simulation training for laparoscopic cholecystectomy: a randomized, controlled trial.

OBJECTIVES As conventional laparoscopic procedural training requires live animals or cadaver organs, virtual simulation seems an attractive alternative. Therefore, we compared the transfer of training for the laparoscopic cholecystectomy from porcine cadaver organs vs virtual simulation to surgery in a live animal model in a prospective randomized trial. DESIGN After completing an intensive training in basic laparoscopic skills, 3 groups of 10 participants proceeded with no additional training (control group), 5 hours of cholecystectomy training on cadaver organs (= organ training) or proficiency-based cholecystectomy training on the LapMentor (= virtual-reality training). Participants were evaluated on time and quality during a laparoscopic cholecystectomy on a live anaesthetized pig at baseline, 1 week (= post) and 4 months (= retention) after training. SETTING All research was performed in the Center for Surgical Technologies, Leuven, Belgium. PARTICIPANTS In total, 30 volunteering medical students without prior experience in laparoscopy or minimally invasive surgery from the University of Leuven (Belgium). RESULTS The organ training group performed the procedure significantly faster than the virtual trainer and borderline significantly faster than control group at posttesting. Only 1 of 3 expert raters suggested significantly better quality of performance of the organ training group compared with both the other groups at posttesting (p < 0.01). There were no significant differences between groups at retention testing. The virtual trainer group did not outperform the control group at any time. CONCLUSIONS For trainees who are proficient in basic laparoscopic skills, the long-term advantage of additional procedural training, especially on a virtual but also on the conventional organ training model, remains to be proven.

Design and implementation of a proficiency-based, structured endoscopy course for medical students applying for a surgical specialty

Background Surgical simulation is becoming increasingly important in surgical education. Despite the important work done on simulators, simulator model development, and simulator assessment methodologies, there is a need for development of integrated simulators in the curriculum. In this paper, we describe the design of our evidence-based preclinical training program for medical students applying for a surgical career at the Centre for Surgical Technologies. Methods Twenty-two students participated in this training program. During their final months as medical students, they received structured, proficiency-based endoscopy training. The total amount of mentored training was 18 hours and the training was organized into three training blocks. The first block focused on psychomotor training, the second block focused on laparoscopic stitching and suturing, and the third block on laparoscopic dissection techniques and hemostasis. Deliberate practice was allowed and students had to show proficiency before proceeding to the next training block. Students’ psychomotor abilities were tested before the course and after each training block. At the beginning of their careers as surgical registrars, their performance on a laparoscopic suturing task was compared with that of registrars from the previous year who did not have this training course. Student opinions about this course were evaluated using a visual analog scale. Results All students rated the training course as useful and their psychomotor abilities improved markedly. All students performed deliberate practice, and those who participated in this course scored significantly (P < 0.0001) better on the laparoscopic suturing task than first year registrars who did not participate in this course. Conclusion Organization of a structured preclinical training program in laparoscopy for final year medical students is feasible, attractive, and successful.

Introducing new technology safely into urological practice

PurposeSurgical innovation is necessary to ensure continued improvement in patient care. However, several challenges unique to the surgical craft are encountered during the development and validation of such new technology. This article highlights some of these challenges and gives an overview of existing solutions.MethodsA Pubmed review was performed about the “introduction of new technology” to identify challenges. Cross-referencing was used to explore the possible solutions per challenge.ResultsSeveral characteristics of the surgical craft itself limit our ability to establish randomised controlled trials and hence provide clear categorical evidence. Existing certification bodies for new technology often use unstructured regulations and allow fast-track bypassing systems. Consequently the IDEAL framework (innovation, development, exploration, assessment, long-term follow-up) proposes an objective scientific approach whilst defining stakeholder responsibilities. The selection of which new modality to implement is heavily influenced by third parties unrelated to the best patient outcomes and thus professional organisations can aid in this decision-making. Appropriate training of surgeons and their teams until proficiency is achieved is essential prior to credentialling. Finally long-term surveillance of outcomes in the form of registries is an increasing responsibility of the urological community to maintain our role in directing the adoption or rejection of these innovations.ConclusionUrological innovation is a dynamic and challenging process. Increasing efforts are identified within the urological community to render the process more reliable and transparent.

Phase III randomised chemoprevention study of Selenium on the recurrence of non-invasive bladder cancer. The SELEnium and BLAdder cancer Trial (SELEBLAT)

Background In Belgium, bladder cancer is the fifth most common cancer in males (5.2%) and the sixth most frequent cause of death from cancer in males (3.8 %). The per-patient lifetime cost is the highest of all other types of cancer. Previous epidemiological studies have consistently reported that selenium concentrations were inversely associated with the risk of bladder cancer. We therefore hypothesized that selenium may also be suitable for chemoprevention of recurrence.

The use of sling vs sphincter in post-prostatectomy urinary incontinence: Sling vs AUS in PPUI

The artificial urinary sphincter (AUS) is considered the ‘gold standard’ in post‐prostatectomy urinary incontinence. However, in recent years, male slings have gained much popularity due to the ease of surgery, good functional results and low complications rates. This review systematically shows the evidence for the different sling systems, describes the working mechanism, and compares their efficacy against that of the AUS. Furthermore subgroups of patients are defined who are not suited to undergo sling surgery.